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The use of technological devices can support the self-management of individuals with type 2 diabetes mellitus (T2DM), particularly in addressing psychological distress. However, there is poor consistency in the literature regarding the use of psychological instruments for the web-based screening of patients’ psychological distress and subsequent monitoring of their psychological condition during digital interventions.
This study aims to review previous literature on the types of psychological instruments delivered in digital interventions for assessing depression, anxiety, and stress in patients with T2DM.
The literature review was conducted using the PsycINFO, CINAHL and PubMed databases, in which the following terms were considered:
In most studies, psychological assessments were administered on paper. A few studies deployed self-reporting techniques employing automated telephonic assessment, a call system for screening and monitoring patients’ conditions and preferences, or through telephone interviews via interactive voice response calls, a self-management support program leveraging tailored messages and structured emails. Other studies used simple telephone interviews and included the use of apps for tablets and smartphones to assess the psychological well-being of patients. Finally, some studies deployed mood rating scales delivered through tailored text message–based support systems.
The deployment of appropriate psychological tools in digital interventions allows researchers and clinicians to make the screening of anxiety, stress, and depression symptoms faster and easier in patients with T2DM. Data from this literature review suggest that mobile health solutions may be preferred tools to use in such digital interventions.
After the diagnosis of type 2 diabetes mellitus (T2DM), people have to follow new lifestyles by changing their physical and psychological habits. According to several studies, T2DM is associated with significant psychological impairments, particularly depression, anxiety, and stress [
This paper intends to identify and outline the types of technological devices through which psychological instruments should be delivered for an accurate assessment of diabetes-related psychological symptoms, such as stress, depression, and anxiety, in which technology represents support aid for self-care and self-management of T2DM. Indeed, a precise assessment of psychological symptoms through technologies in the field of diabetes is crucial to identify and understand problematic areas to better manage the disease itself, reduce such symptoms, and facilitate the management of the disease itself. Although the number of psychological instruments designed specifically for diabetes has increased, reviews of psychological instruments integrated into technological devices for assessing psychological symptoms are generally scarce among patients with T2DM. More specifically, the aim of this review is two-fold: (1) to summarize the types of technological devices used to administer self-report questionnaires for the assessment of psychological symptoms among individuals with T2DM, with a specific focus on the efficacy and usability of these tools and (2) to summarize the principal instruments as well as their psychometric characteristics to assess psychological symptoms related to T2DM, with a focus on symptoms of anxiety, stress, and depression, through the use of technology.
This literature review sheds light on the types of technological devices through which psychological instruments were used to assess psychological distress among adults with T2DM. This review was conducted through the academic databases PubMed (360 articles), PsycINFO (165 articles), and CINAHL (239 articles) in which the following terms and their derivatives were considered during the search: diabetes mellitus, measure, assessment, self-care, self-management, depression, anxiety, stress, technology, eHealth, mobile health, mobile phone, device, and smartphone. More specifically, the terms self-care and self-management have been used as search words to find articles in which technological devices are mentioned. Moreover, according to the Cambridge Dictionary, the term device refers to a machine, for instance, a phone or a computer, which can be used to connect to the internet [
The studies included in the review were in line with the following inclusion criteria: (1) presence of technological support for mental health assessment delivered to patients with T2DM; (2) studies with at least 60% of participants with T2DM, in order to have most people with only T2DM, the target population of this study; (3) studies that focused on depression, anxiety, stress, or other psychological symptoms in patients with T2DM; and (4) samples comprising adults aged between 18 and 70 years who may present with psychological distress, with a focus on depression, anxiety, and/or stress symptoms related to T2DM.
Studies that met any of the following criteria were excluded: (1) absence of technological support for mental health assessment; (2) studies involving patients with other chronic conditions or primary diseases (eg, cardiovascular disease, cardiomyopathy, chronic kidney disease) or psychiatric disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [
On the basis of the inclusion and exclusion criteria, 17 articles were eligible for the literature review.
Most studies (6 articles) were conducted in paper-based format—at baseline and follow-up—through written questionnaires provided by the staff or employing interviews before the technological intervention to evaluate the psychological distress and health-related quality of life of patients with T2DM [
The use of information and communication technology (ICT) apps in health care settings is increasing globally. Indeed, a useful way of communicating preventive methods to the population is through ICT [
Most studies included in the review reported only the name of the instrument, thereby not providing information regarding the psychometric properties of the tools, such as reliability, validity, data monitoring, contextual collection, and/or whether the instrument was specified for the population with diabetes [
Another instrument that is widely used to assess depressive symptoms through technologies is the Patient Health Questionnaire-9 (PHQ-9); indeed, 9 studies administered the above questionnaire [
A summary of the types of technological solutions through which patient screening and psychological assessment were conducted is presented in
Paper-and-pencil questionnaires
Advantages
More cost-effective when surveying data in small samples
Could increase a working alliance because of human interaction
Benefits people who do not have internet access
More favorable format when it comes to longer questionnaires
No digital skills are required to answer
Disadvantages
Lack of immediate data analysis
Data entry is needed to store them in databases
Handwritten responses could be difficult to interpret, especially when it comes to open-ended questions
Needs longer data processing
Printing and archiving of the questionnaires are needed
There is the option of skipping questions
Human errors can occur when updating the database
Questionnaires through digital solutions
Advantages
Save time for clinicians and researchers
Faster in delivering the questionnaires
Directly collect data on the web
Furnish an immediate feedback
Collect data from people around the world
More ecological (ie, no printing and other costs at the point of completing setup)
Better graphic layout (ie, not only color images and text, but also dynamic and interactive animation)
Collect all the responses, thereby avoiding unanswered questions
Allows longer answers to open-ended questions
Gives more time to fill in the questionnaires
Disadvantages
Familiarity with digital devices is required
Possible difficulties for data analysis derived from people filling-in the questionnaire multiple times, which would bias the results
Lack of technological devices
Technical problems
Unreliable network
This study aimed to review past literature regarding the types of technological devices used to administer psychological instruments for assessing psychological distress (ie, depressive, anxiety symptoms) and stress in patients with T2DM. Assessing diabetes-related psychological symptoms can be challenging, due in part to the complexity of diabetes care. Indeed, diabetes self-care should be multidimensional, including treatment for both organic and psychological symptoms, whereas at the same time, it should use technology-based tools, which show good psychometric properties and are validated by samples of patients with chronic diseases.
First, studies seem to focus on the evaluation of psychological distress and diabetes-specific distress, particularly anxiety, depression, and stress symptoms. Indeed, instruments that measure symptoms of anxiety, stress, and depression related to T2DM, administered through technologies, were analyzed, and their efficacy and usability were evaluated. In this context, the psychometric properties of the instruments are prerequisites for an accurate assessment of psychological distress in patients with diabetes. Inadequate reliability and validity of the tools make it difficult to detect the psychological well-being of patients with diabetes and the impact of interventions on their well-being or quality of life. Here, the timing of the test can influence its reliability and validity, and therefore it needs to be taken into consideration. Within a longitudinal evaluation of an intervention, if the duration of the test was too short, participants could recall information from the first time they completed it, which could bias the findings. Alternatively, if its duration was too long, participants may have changed significantly, which could also bias the results [
In most studies, screening was conducted using written questionnaires at baseline and after a follow-up as well as telephone interviews (ie, simple telephone interviews, ATA calls, and IVR) to assess psychological symptoms [
Few studies have used digital solutions, such as mobile apps, tablets, and computers, to deliver psychological self-reports for intervention groups, even though they were investigating the psychological symptoms related to the disease itself [
Second, the PHQ-9 and the DDS-17 emerged as useful tools for the assessment of depressive symptoms in chronic diseases and for problems often experienced by these patients, such as emotional burden, interpersonal distress, or regimen-related distress [
Moreover, considering the importance of the role of self-efficacy in the management of emotion-related diabetes, it is recommended that researchers and clinicians use specific tools to address self-efficacy in those patients. Of particular note is the fact that most studies used psychological tools in the standard paper format to assess the effectiveness of interventions without integrating them into digital solutions. Indeed, in this review, few studies delivered web-based questionnaires [
In this study, the integration of assessment instruments in digital solutions improved the assessment of depressive and anxiety symptoms. Thus, research suggests that mHealth interventions are functional ways of supporting the treatment of depression and anxiety symptoms [
This review presents some limitations, as it included only papers in English, which limits the generalization of the findings. In addition, a limitation could be identified in the different implications regarding the use of technological devices from the age of 18 to 70 years. Older adults may be less familiar with the use of these devices. Future work should evaluate the effect of the use of technological devices among individuals of different ages. In the context of digital solutions, the disadvantage of smartphone-, tablet-, or computer-based apps is that they can be removed by the user; however, such device-based apps and other conversational agents can represent a valuable solution in administering psychological tools for the screening of patients, especially in emergency situations such as the SARS-CoV-2 pandemic. Furthermore, most studies do not provide information regarding the psychometric properties of tools, such as reliability, validity, and contextual collection. It could be important to include such characteristics to better understand the instruments used for assessing psychological distress and diabetes-specific distress. Another limitation is the noninclusion of videoconference calling as a digital solution, which especially during the COVID-19 lockdown represented the method of choice among practitioners in psychology and psychiatry for a remote assessment of mental health. Future studies should include these types of technological solutions to expand this literature review.
Finally, the focus of the review was only on psychological measures related to T2DM. In future works, one would recommend the integration of the assessment and monitoring of both organic and psychological symptoms in patients with T2DM.
On the other hand, this review also has some strengths. In addition to depression, the review considered all possible psychological symptoms related to T2DM.
This review highlighted implications that may have an impact on future research and clinical practice. In particular, the use of appropriate technological solutions to assess the psychological condition of patients can allow early detection of depression, stress, and anxiety symptoms, especially in chronic conditions as well as mental disorders [
In view of the large increase in the number of patients with diabetes globally, it is important to intensify efforts in the deployment of digital solutions for the accurate assessment of patients’ psychological condition. These instruments can be useful for clinicians and researchers to better monitor patients’ conditions. For example, the mood rating scale is widely used in studies to assess diabetes-related stress and depression. Therefore, the identification of appropriate psychological tools that can be deployed through mHealth solutions allows researchers and clinicians to screen for anxiety, stress, and depression in patients with T2DM in a faster and easier way. Moreover, data from the literature suggest that mHealth interventions are preferable to other types of digital interventions [
Articles from the literature review.
Description of the psychological instruments.
automated telephonic assessment
Diabetes Distress Scale-17
information and communication technology
interactive voice response
mobile health
Medical Outcome Study Short-Form Health Survey
Patient Health Questionnaire-9
type 2 diabetes mellitus
None declared.